Download urgent referral for patients with suspected upper gi cancer

URGENT REFERRAL FOR PATIENTS WITH SUSPECTED UPPER GI CANCER
Box A
Note: Please refer patients with the following symptoms for
GP Direct Access 2WW Abdominal Imaging
2WW USS abdomen:
Any age with abdominal mass consistent with enlarged gall-bladder or liver but NOT jaundiced
2WW CT abdomen & pelvis
Aged 60 years and over with unexplained weight loss
PLUS any of the following: diarrhoea, constipation, back pain or new onset diabetes mellitus
2WW abdominal Imaging studies which suggest malignancy will be notified to:the referring GP advising that an urgent referral to the relevant cancer MDT is required
and to the relevant cancer MDT lead
Patient Details
Surname:
Forename(s):
Address (inc postcode):
Date of Birth:
Gender:
NHS Number:
Hospital Number:
Telephone Numbers
Tel No (Home):
Tel No (work):
Tel No (Mobile):
Please check tel no's with patient
GP Details
Referring GP:
Practice Name:
Practice Address:
GP Tel No:
Practice Email Address:
Date of decision to refer:
Patient Information
Yes
Yes
Yes
Does your patient have a learning disability?
Is your patient able to give informed consent?
Is your patient fit for day case investigation?
If a translator is required, please specify language:
Is patient on any of the following medications?
Yes
Aspirin
Yes
Clopidogrel /Prasugrel etc .
Yes
Warfarin
Yes
NOAC (Rivaroxaban etc.)
Yes
Insulin
No
No
No
No
No
No
No
No
Indication for therapy:
Indication for therapy:
Indication for therapy:
Indication for therapy:
Please confirm that the patient is aware that this is a suspected cancer referral:
Yes
No
Date(s) that patient is unable to attend within the next two weeks:
If patient is not available for the next 2 weeks, and aware of nature of referral, consider seeing patient again to reassess symptoms and
refer when able and willing to accept an appointment.
The above details are required before we can begin booking appointments
HOSPITAL USE ONLY. OUTCOME OF CONSULTANT TRIAGE:



 2WW OGD
4WW OGD
ROUTINE OGD
COMMENTS:
Version 3 May 2016
ANYONE
CONSULTANT
STOP PPI
2WW CT – RESULT TO CONS
2WW USS – RESULT TO CONS
2WW CLINIC
 OTHER
INITIALS & DATE:
It would be helpful if you could provide performance status information (please tick as appropriate)
Fully active
Able to carry out light work
Up & about 50% of waking time
Limited to self-care, confined to bed/chair 50%
No self-care, confined to bed/chair 100%
Level of Cancer Concern
Level of concern
(optional)
“I’m pretty sure my patient has cancer”
“I’m unsure, it might well be cancer but there are other equally plausible explanations.”
“I don’t think my patient has cancer but I would like to rule it out.”
“Doesn’t meet criteria but I have a cancer concern”
Reasons for referring
Please detail patient and relevant family history, examination and investigation findings, your conclusions and what needs excluding
or attach referral letter.
Version 3 May 2016
PLEASE TICK ALL BOXES THAT APPLY BELOW
ENSURE THAT RECENT FBC AND LFTS AVAILABLE
Referral Criteria
BOX B
4WW GASTROSCOPY PATHWAY:
(Risk of UGI cancer approximately 1%, ensure patient available for OGD within 4 weeks)
Aged 55 or over with ANY OF THE FOLLOWING:
nausea/vomiting PLUS involuntary weight loss
nausea/vomiting PLUS reflux symptoms
nausea/vomiting PLUS raised platelet count
involuntary weight loss PLUS raised platelet count
reflux symptoms PLUS raised platelet count
treatment resistant dyspepsia
upper abdominal pain PLUS low haemoglobin OR raised platelet count
Small volume haematemesis AT ANY AGE
BOX C
2WW GASTROSCOPY PATHWAY:
(Risk of UGI cancer approximately 3%, ensure patient available for OGD within 2 weeks)
Dysphagia at any age
Aged 55 or over with involuntary weight loss PLUS upper abdominal pain
Aged 55 or over with involuntary weight loss PLUS reflux symptoms
Aged 55 or over with involuntary weight loss PLUS dyspepsia (abdominal discomfort)
BOX D
2WW JAUNDICE CLINIC PATHWAY:
(Risk of HPB cancer >15%, ensure patient available for Specialist Clinic Within 2 Weeks)
Aged 40 or over with recent onset jaundice: Bilirubin =
ALP =
AST =
BOX E
PATIENTS WHO DO NOT MEET THE ABOVE CRITERIA :
Patient does not meet the above criteria but I wish to refer (details in clinical summary below)
Version 3 May 2016
Clinical Summary
Clinical History (significant past and current medical history):
Current medication:
Blood Tests (if available – last 3 months):
Allergiesl
Smoking:
BMI (if available):
Alcohol (if available):
ALL REFERRALS ARE REVIEWED BY A CONSULTANT
GASTROENTEROLOGIST WITHIN ONE WORKING DAY
In the event that the e-referral service is not available – please email to [email protected] and title as
“2ww urgent referral”
Version 3 May 2016